Diagnosis and Management of Babesiosis

Publication Date: January 14, 2021
Last Updated: March 22, 2022

Diagnosis

For diagnostic confirmation of acute babesiosis, IDSA recommends peripheral blood smear examination or PCR rather than antibody testing. ( S , M)

Comment: The diagnosis of babesiosis should be based on epidemiological risk factors and clinical evidence, and confirmed by blood smear examination or PCR.

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For patients with a positive Babesia antibody test, IDSA recommends confirmation with blood smear or PCR before treatment is considered. ( S , M)

Comment: A single positive antibody test is not sufficient to establish a diagnosis of babesiosis because Babesia antibodies can persist in blood for a year or more following apparent clearance of infection, with or without treatment.

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Treatment

IDSA recommends treating babesiosis with the combination of atovaquone plus azithromycin or the combination of clindamycin plus quinine. ( S , M)
Comment: Atovaquone plus azithromycin is the preferred antimicrobial combination for patients experiencing babesiosis while clindamycin plus quinine is the alternative choice. The duration of treatment is 7–10 days in immunocompetent patients but often is extended when the patient is immunocompromised (Table 1).
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In selected patients with severe babesiosis, IDSA suggests exchange transfusion using red blood cells. ( W , L)

Comment: Exchange transfusion may be considered for patients with high-grade parasitemia (>10%) or who have any one or more of the following: severe hemolytic anemia and/or severe pulmonary, renal, or hepatic compromise. Expert consultation with a transfusion services physician or hematologist in conjunction with an infectious diseases specialist is strongly advised.

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For immunocompetent patients, IDSA recommends monitoring Babesia parasitemia during treatment of acute illness using peripheral blood smears but recommend against testing for parasitemia once symptoms have resolved. ( S , M)
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For immunocompromised patients, IDSA suggests monitoring Babesia parasitemia using peripheral blood smears even after they become asymptomatic and until blood smears are negative. PCR testing should be considered if blood smears have become negative but symptoms persist. ( W , M)
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Recommendation Grading

Overview

Title

Diagnosis and Management of Babesiosis

Authoring Organization

Infectious Diseases Society of America

Endorsing Organizations

American Academy of Neurology

American College of Rheumatology

Publication Month/Year

January 14, 2021

Last Updated Month/Year

November 25, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this guideline is to provide evidence-based guidance for the most effective strategies for the diagnosis and management of babesiosis

Target Patient Population

Patients with babesiosis

Target Provider Population

Infectious diseases specialists, emergency physicians, intensivists, internists, pediatricians, hematologists, and transfusion medicine specialists.

PICO Questions

  1. How Should the Diagnosis of Babesiosis Be Confirmed?

  2. Can an Active Case of Babesiosis Be Diagnosed Based on a Single Positive Antibody Test or Is a Blood Smear, PCR, or a Four-fold Rise in Antibody Necessary for Confirmation?

  3. What Are the Preferred Treatment Regimens for Babesiosis?

  4. Is Exchange Transfusion Indicated for Severe Babesiosis?

  5. How Should Immunocompetent and Immunocompromised Patients Be Monitored After Babesiosis Therapy Is Initiated? How Frequently and for How Long?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D001404 - Babesiosis

Keywords

clindamycin, babesiosis

Source Citation

Peter J Krause, Paul G Auwaerter, Raveendhara R Bannuru, John A Branda, Yngve T Falck-Ytter, Paul M Lantos, Valéry Lavergne, H Cody Meissner, Mikala C Osani, Jane Glazer Rips, Sunil K Sood, Edouard Vannier, Elizaveta E Vaysbrot, Gary P Wormser, Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis, Clinical Infectious Diseases, ciaa1216, https://doi.org/10.1093/cid/ciaa1216

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
103
Literature Search Start Date
February 29, 2016
Literature Search End Date
March 31, 2019